1、Chapter 14Initial TherapyPhase therapy is the first step in the chronologic sequence of procedures that constitute periodontal treatment.The objective of Phase therapy is to alter or eliminate the microbial etiology and contributing factors for gingival and periodontal diseases.The result is the arr
2、esting of the progression of disease and preservation of the dentition in a state of health,comfort,and function with appropriate esthetics.Scetion 1 Plaque ControlPlaque control is the removal of dental plaque on a regular basis and the prevention of its accumulation on the teeth and adjacent gingi
3、val surfaces.It is a critical component of dental practice,permitting long-term success of periodontal and dental care.Plaque control is the most effective means of preventing accumulation of microbial dental deposits,thereby interfering with the initiation,development,or progression of periodontal
4、disease.Patient Evaluation and Education Phase microscope Disclosing solution Disclosing tablet Plaque IndexPlaque Control Record Methods:1.ToothbrushingBass methodRolling methodCharters methodToothbrushing The Bass method is a preferred method of brushing.It involves placing the tooth brush head at
5、 a 45 degree angle along the gumline,pointing downwards on the bottom teeth and upwards on the top teeth.The tips of the toothbrush bristles should go underneath the gumline.The toothbrush is gently vibrated,not scrubbed,along the gumline spending about 3 seconds on each tooth.The entire process of
6、brushing should last 3-4 minutes(about the length of one song on the radio!)Bass method.A,Place the toothbrush so that the bristles are angled approximately at 45 degrees from the tooth surfaces.B,Start at the most distal tooth in the arch and use a vibrating,back-and-forth motion to brush.ABABBass
7、method.A,Proper position of the brush in the mouth aims the bristle tips toward the gingival margin.B,Diagrams shows the ideal placement,which could permit slight subgingival penetration of the bristle tips.Bass method.The correct palatal position on molars and premolars is with the bristle tips at
8、the gingival margin as shown in the diagram,not on the occlusal surfaces.Bass method.Palatal position of the soft toothbrush on the molars and premolars permits bristle tip penetration into the interproximal areas and possibly slightly subgingivally.Bass method.Adjusting the palatal position of the
9、toothbrush on incisors,as shown in the diagram,may provide better access for plaque removal.Bass method.Placement of the bristles on the palatal surfaces of the incisor teeth can be difficult and often requires this modified approach.This brush position on occlusal surfaces of the teeth is used with
10、 any technique,including the Bass,Stillman,or Charters method.Place bristles along the gumline at a 45-degree angle.Bristles should contact both the tooth surface and the gumline.Gently brush the outer tooth surfaces of 2-3 teeth using a vibrating back&forth rolling motion.Move brush to the next gro
11、up of 2-3 teeth and repeat.Maintain a 45-degree angle with bristles contacting the tooth surface and gumline.Gently brush using back,forth,and rolling motion along all of the inner tooth surfacesTilt brush vertically behind the front teeth.Make several up&down strokes using the front half of the bru
12、sh.Place the brush against the biting surface of the teeth&use a gentle back&forth scrubbing motion.Brush the tongue from back to front to remove odor-producing bacteria.2.Dental flossWrap most of the floss on the middle finger of the right hand and the rest around the middle finger of the left hand
13、.As you are flossing,take up the floss on the other finger like a scroll to provide fresh floss.Use index fingers and thumbs as guides for flossing the upper teeth and index fingers for the lower teeth.Hold the floss tightly and work it gently between the teeth.Be very careful not to snap the floss
14、between teeth and under gums because this can harm the delicate tissue.Curve the floss around the tooth and carefully work it apically.Work the floss into the sulcus.Holding the floss tightly against the tooth,scrape toward the point where the tooth touches its neighbor.Repeat this step on the adjac
15、ent tooth.Set a pattern for flossing,and follow the same pattern every time so that all the teeth are flossed.Wind 20cm of floss around middle fingers of each hand.Pinch floss between thumbs and index fingers,leaving a 11.5cm length in between.Use thumbs to direct floss between upper teeth.Keep a 11
16、.5cm length of floss taut between fingers.Use index fingers to guide floss between contacts of the lower teethGently guide floss between the teeth by using a zig-zag motion.DO NOT SNAP FLOSS BETWEEN YOUR TEETH.Contour floss around the side of the tooth.Slide floss up and down against the tooth surfa
17、ce and under the gumline.Floss each tooth thoroughly with a clean section of flossTriangular toothpicksInterproximal brushesYarnGauze stripsWater irrigation devicesElectric toothbrushOther aids:Cleaning of concave or irregular proximal tooth surfaces.Dental floss(A)may be less effective than an inte
18、rdental brush(B)on long root surfaces with concavities.Interproximal embrasure spaces vary greatly in patients with periodontal disease.In general,embrasures with no gingival recession are adequately cleaned using dental floss(A);larger spaces with exposed root surfaces require the of an interproxim
19、al brush(B);and single-tufted brushes clean efficiently in interproximal spaces with no papillae(C).3.Chemical Plaque ControlAdministration:1.Mouthwashes2.Dentifrices3.Chewing gums4.Syringes for pocket irrigationAgents:Tensioactive agents (fluoride,1.64%SnF,silicones etc)Antibiotics (tetracyclines,k
20、anamycin,spiramycin,metronidazole etc)Antiseptics (chloramine T,chlorhexidine salts)Enzymes (dextranases,trypsin,lipase)Dietary substancesStain following two weeks rinsing with 0.12%chlorhexidine.Depending on the location of the calculus,scaling is divided into either supragingival or subgingival in
21、strumentation.The objective of supragingival scaling is the removal of deposits from the clinical crowns of the teeth.Subgingival scaling is the removal of deposits below the gingival margin.Section 3 Scaling and Root Planing Definition:Scaling and root planing are techniques of instrumentation appl
22、ied to the root surface to remove plaque,calculus,and altered or roughened cementum.When thoroughly performed,these techniquees leave a smooth,clean,hard,and polished root surface.Goals:The purpose of scaling and root planing is to eliminate the etiologic agents causing inflammation,bacterial plaque
23、,and its products on and in the tooth,and calculus.Rationale for root planning:The rationale for planing root surfaces is to remove calculus and cementum containing endotoxin and to smooth the root surfaces.Applicability:1.Edematous and fibrotic gingivae2.Phase 1 therapy3.Maintenance therapy4.Prepar
24、ation of prosthetic,orthodontic and operative therapyInstruments and instrumentationInstruments used for scaling and root planing are classified as:Hand instruments(curettes,sickles,hoes)Ultrasonic and sonic instruments(ultrasonic scalers)Supragingival Scalingv Sickles v Hoes Subgingival Scalingv Un
25、iversal Curettes v Gracey curettesv Hoes v Files Gracey CuretteUniversal CurettesArea of useSet of many curettes designed for specific areas and surfaces One curette designed for all areas and surfacesCutting Edge Use One cutting edge used;work with outer edge onlyBoth cutting edges used;work with e
26、ither outer or inner edgeCurvatureCurved in two planes:blade curves up and to the sideCurved in one plane:blade curves up,not to sideBlade angleOffset blade:face of blade beveled at 70 degrees to shankNot offset:face of blade beveled at 90 degrees to shankGracey 5/6:For anterior teeth;have long,stra
27、ight shanksGracey 7/8:For facial and lingual surfaces of posterior teethGracey 11/12:For mesial surfaces of posterior teethGracey 13/14:For distal surfaces of posterior teeth Gracey#5-6 curette adapted to an anterior tooth.Gracey#7-8 curette adapted to the facial surface of a posterior tooth.Gracey#
28、11-12 curette adapted to the mesial surface of a posterior tooth.Gracey#1314 curette adapted to the distal surface of a posterior tooth.Primer on Instrumentation Grasp Modified pen grasp Palm grasp Fulcrums Working Stroke Hand Position Patient/operator Position Modified pen grasp.The pad of the midd
29、le finger rests on the shank.Standard pen grasp.The side of the middle finger rests on the shank.Palm and thumb grasp,used for stabilizing instruments during sharpening.The fulcrum is the stabilizing and pivotal point from which the working stroke used in scaling and root planing can occur.Built-up
30、fulcrumSplit fulcrumIntraoral conventional finger rest.The fourth finger rests on the occlusal surfaces of adjacent teeth.Intraoral cross-arch finger rest.The fourth finger rests on the incisal surfaces of teeth on the opposite side of the same arch.Intraoral opposite-arch finger rest.The fourth fin
31、ger rests on the mandibular teeth while the maxillary posterior teeth are instrumented.Intraoral finger-on-finger rest.The fourth finger rests on the index finger of the nonoperating hand.Extraoral palm-up fulcrum.The backs of the fingers rest on the right lateral aspect of the mandible while the ma
32、xillary right posterior teeth are instrumented.Extraoral palm-down fulcrum.The front surfaces of the fingers rest on the left lateral aspect of the mandible while the maxillary left posterior teeth are instrumented.Index finger-reinforced rest.The index finger is placed on the shank for pressure and
33、 control in the maxillary left posterior lingual region.Thumb-reinforced rest.The thumb is placed on the handle for control in the maxillary right posterior lingual region.The curette blade.The back third is that part nearest the shank of the instrument.The toe third extends from the rounded tip of
34、the blade to approximately one-third the distance of the length of the blade.Blade adaptation.A,Blade in proper contact.The toe third of the blade is used.B,Improper contact of back third of blade with tooth,leading to tissue laceration by toe of blade.C,Figure of the tip of the blade adapted to the
35、 tooth surface,leading to tissue distention and tooth gouging.Root planing strokes are multidirectional.Patient-operator positioning The patient position is supine for access to the maxillary arch.The back of the patients chair is raised to a 30 to 40 degree angle to the floor to access the mandibul
36、ar arch.Subgingival scaling procedure.A,Curette inserted with the face of the blade flush against the tooth.B,Working angulation(45 to 90 degrees)is established at the base of the pocket.C,Lateral pressure is applied,and the scaling stroke is activated in the coronal direction.Maxillary right poster
37、ior sextant:facial aspectOperator position:Side position.Illumination:Direct.Visibility:Direct(indirect for distal surfaces of molars).Retraction:Mirror or index finger of the nonoperating hand.Finger rest:Extraoral,palm up.Backs of the middle and fourth fingers on the lateral aspect of the mandible
38、 on the right side of the face.Maxillary right posterior sextant,premolar region only:facial aspect Operator position:Side or back position.Illumination:Direct.Visibility:Direct.Retraction:Mirror or index finger of the nonoperating hand.Finger rest:Intraoral,palm up.Fourth finger on the occlusal sur
39、faces of the adjacent maxillary posterior teeth.Maxillary right posterior sextant:lingual aspectOperator position:Side or front position.Illumination:Direct and indirect.Visibility:Direct or indirect.Retraction:None.Finger rest:Extraoral,palm up.Backs of the middle and fourth fingers on the lateral
40、aspect of the mandible on the right side of the face.Maxillary right posterior sextant:lingual aspectOperator position:Front position.Illumination:Direct.Visibility:Direct.Retraction:None.Finger rest:Intraoral,palm up,finger on finger.Index finger of the nonoperating hand on the occlusal surfaces of
41、 the maxillary right posterior teeth;fourth finger of the operating hand on the index finger of the nonoperating hand.Maxillary anterior sextant:facial aspect,surfaces away from the operatorOperator position:Back position.Illumination:Direct.Visibility:Direct.Retraction:Index finger of the nonoperat
42、ing hand.Finger rest:Intraoral,palm up.Fourth finger on the incisal edges or occlusal surfaces of adjacent maxillary teeth.Maxillary anterior sextant:facial aspect,surfaces toward the operatorOperator position:Front position.Illumination:Direct.Visibility:Direct.Retraction:Index finger of the nonope
43、rating hand.Finger rest:Intraoral,palm down.Fourth finger on the incisal edges or the occlusal or facial surfaces of adjacent maxillary teeth.Maxillary anterior sextant:lingual aspect,surfaces away from the operator(surfaces toward the operator are scaled from a front position)Operator position:Back
44、 position.Illumination:Indirect.Visibility:Indirect.Retraction:None.Finger rest:Intraoral,palm up.Fourth finger on the incisal edges or the occlusal surfaces of adjacent maxillary teeth.Maxillary left posterior sextant:facial aspect Operator position:Side or back position.Illumination:Direct or indi
45、rect.Visibility:Direct or indirect.Retraction:Mirror.Finger rest:Extraoral,palm down.Front surfaces of the middle and fourth fingers on the lateral aspect of the mandible on the left side of the face.Maxillary left posterior sextant:facial aspect Operator position:Back or side position.Illumination:
46、Direct or indirect.Visibility:Direct or indirect.Retraction:Mirror.Finger rest:Intraoral,palm up.Fourth finger on the incisal edges or the occlusal surfaces of adjacent maxillary teeth.Maxillary left posterior sextant:lingual aspect Operator position:Front position.Illumination:Direct.Visibility:Dir
47、ect.Retraction:None.Finger rest:Intraoral,palm down,opposite arch,reinforced.Fourth finger on the incisal edges of the mandibular anterior teeth or the facial surfaces of the mandibular premolars,reinforced with the index finger of the nonoperating hand.Maxillary left posterior sextant:lingual aspec
48、t Operator position:Front position.Illumination:Direct and indirect.Visibility:Direct and indirect.Retraction:None.Finger rest:Extraoral,palm down.Front surfaces of the middle and fourth fingers on the lateral aspect of the mandible on the left side of the face.The nonoperating hand holds the mirror
49、 for indirect illumination.Maxillary left posterior sextant:lingual aspect Operator position:Side or front position.Illumination:Direct.Visibility:Direct.Retraction:None.Finger rest:Intraoral,palm up.Fourth finger on the occlusal surfaces of adjacent maxillary teeth.Mandibular left posterior sextant
50、:facial aspect Operator position:Side or back position.Illumination:Direct.Visibility:Direct or indirect.Retraction:Index finger or mirror of the nonoperating hand.Finger rest:Intraoral,palm down.Fourth finger on the incisal edges or the occlusal or facial surfaces of adjacent mandibular teeth.Mandi
